The effect of preperitoneal pelvic packing for hemodynamically unstable patients with pelvic fractures

Abstract

Purpose Hemodynamically unstable patients with pelvic fractures still represent a challenge to trauma surgeons and have a very high mortality. This study was designed to explore the effect of the interventions of direct preperitoneal pelvic packing for the hemodynamically unstable pelvic fractures. Methods This retrospective study enrolled 67 cases of severe pelvic fractures with unstable hemodynamics from October 2011 to December 2019. All patients presented in our emergency center and received preperitoneal pelvic packing were included in this study. The indication was persistent systolic blood pressure ≤90 mmHg during initial resuscitation and after transfusion of two units of red blood cells. Patients with hemodynamic stability who need no preperitoneal pelvic packing to control bleeding were excluded. Their demographic characteristics, clinical features, laboratory results, therapeutic interventions, adverse events, and prognostic outcomes were collected from digital information system of electronic medical records. Statistics were described as mean ± standard deviation or medium and analyzed using pair sample t -test or Mann-Whitney U - test. Results The patients’ average age was 41.6 years, ranging from 10 to 88 years. Among them, 45 cases were male (67.2%) and 22 cases were female (32.8%). Significant difference was found regarding the systolic blood pressure (mmHg) in the emergency department (78.4 ± 13.9) and after preperitoneal pelvic packing in the surgery intensive care unit (100.1 ± 17.6) ( p < 0.05). Simultaneously, the arterial base deficit (mmol/L) were significantly lower in the surgery intensive care unit (median -6, interquartile range -8 to -2) than in the emergency department (median -10, interquartile range -14 to -8) ( p < 0.05). After preperitoneal pelvic packing, 15 patients (22.4%) underwent pelvic angiography for persistent hypotension or suspected ongoing haemorrhage. The overall mortality rate was 29.5% (20 of 67). Conclusions Preperitoneal pelvic packing, as a useful surgical technique, is less invasive and can be very efficient in early intra-pelvic bleed control.

Predictive factors of mortality in patients with pelvic fracture and shock submitted to extraperitoneal pelvic packing

“…In addition, the need for transfusions after EPP and in the next 24 hours decreased 5,9,10,12,21,26,28,29 . In our series, patients who died received significantly more blood products.…”

“…Other studies that published their experience with EPP [5][6][7]9,10,[12][13][14][15][16]21,[26][27][28][29] also reported a high mean ISS, between 30 and 55, though with lower mortality, ranging from 7.14% to 36.3%. Cheng et al 6 reported 61% of patients with extrapelvic lesions with AIS ≥4, while Burlew et al 5 reported that 85% of patients required other surgical procedures (on average, three procedures in addition to EPP and pelvis EF), with a mean ISS of 48.…”

“…Patients with refractory shock after resuscitation with adequate volume and mechanical stabilization of the pelvis are more likely to have arterial injury 35 , with a reported incidence greater than 50% 7,14,[36][37][38][39][40] , making this the most frequent indication for arteriography 41,42 . In studies on EPP results [5][6][7]9,10,[12][13][14][15][16]21,[26][27][28][29] , arteriography was performed in a complementary way in 13,33% to 100% of patients, and the presence of arterial injury was confirmed in 33.33% to 100% of cases. The prevalence of arterial injury in these studies varied widely, from 14.25% to 88% among patients with hemodynamic instability undergoing EPP.…”

Fatores preditivos de mortalidade em pacientes com fratura de pelve e instabilidade hemodinâmica submetidos ao tamponamento extraperitoneal de pelve

“…Considerando estudos que publicaram suas experiências com TXP 5,7,9,10,[12][13][14]21,26,28,29 , exceto o estudo publicado por Cheng et al 6 , todos apresentaram maior média de unidades transfundidas antes do TXP, variando de 3,7 a 12 unidades de CH. Além disso, essas transfusões ocorreram em menos tempo, variando de 22 (±8) minutos a 82 (±13) minutos, exceto no estudo publicado por Totterman et al 14 .…”

“…A maior quantidade de CH recebida em menos tempo antes do TXP provavelmente resultou na melhora da perfusão tecidual e no controle do sangramento em um estágio anterior, antes do desenvolvimento da coagulopatia. Além disso, a necessidade de transfusões após o TXP, e nas próximas 24h, diminuiu 5,9,10,12,21,26,28,29 .…”